Anatomy and diagnosis
ANATOMY OF THE FEMALE
REPRODUCTIVE SYSTEM
Anatomy and diagnosis
ANATOMY OF THE FEMALE
REPRODUCTIVE SYSTEM
Anatomy and diagnosis
POSITION OF THE
UTERUS
Suspension- support for the uterus by
ligaments
Supposition- support for the uterus by
fasciae
Ante(retro-)flexion- the angle between the
long axis of the corpus and the cervix
Ante(retro-)version- the angle between the
long axis of the cervix and the vagina
Anatomy and diagnosis
Anatomy and diagnosis
The muscles supported the
uterus
Urogenital diaphragm:
•
Deep transverse muscle of perineum
•
Sphincter muscle of urethra
Pelvic diaphragm:
Levator ani muscle
Coccygeal muscle
Superficial layer of muscles:
•
Bulbocavernous muscle
•
Ischiocavernous muscle
•
Superficial transverse muscle of perineum
•
Anal sphincter muscle
Anatomy and diagnosis
Anatomy and diagnosis
Anatomy and diagnosis
Anatomy and diagnosis
Anatomy and diagnosis
Anatomy and diagnosis
Gynecological examinations
Screening examinations
Basic examinations
Additional
examinations
Anatomy and diagnosis
Basic examination
History
complaints, age, menstrual history (first menstrual
period, last menstrual period), obstetric history
(gravidity and parity, abortions), past surgery, cervical
procedures, diseases, applied hormonal therapy etc.
Physical examination
Gynecological examination
Breast examination
Anatomy and diagnosis
Additional examinations
Colposcopy→ biopsies of suspicious areas
of cervical disc; cervical conisation
Transabdominal and transvaginal
ultrasonography,
Labolatory studies,
HSG,
diagnostic laparoscopy and hysteroscopy
Anatomy and diagnosis
Screening examinations
Pap smear: annually from onset of
sexual
activity or age
18
when suspicious results repeat after 3 months
Mammography: at the age of 40, next
after 5
years
at the age of >45 every
year
Anatomy and diagnosis
Pelvic examination
•
Inspection and examination of the
external genitalia
•
Speculum examination
•
Pap smear
•
Cultures
•
Bimanual examination of the uterus and
adnexa
•
Per rectum examination
•
Rectovaginal examination
Anatomy and diagnosis
Anatomy and diagnosis
ULTRASONOGRAPHY
Anatomy and diagnosis
Ultrasonography, pelvic. Transabdominal
longitudinal view of the female pelvis.
Anatomy and diagnosis
Ultrasonography, pelvic. Transabdominal
transverse view of the female pelvis: The
bladder is rectangular.
Anatomy and diagnosis
Ultrasonography, pelvic. Endovaginal
longitudinal view of the uterus: The
endometrial stripe (st) is thickened.
Anatomy and diagnosis
Ultrasonography, pelvic. Endovaginal
view of the ovary: Note its location
adjacent to an iliac vessel.
Anatomy and diagnosis
Pap Smear
Papanicolau
Bethesda
Anatomy and diagnosis
Pap smear classification
Pap smear classification
Papanicolaou (1943)- normal
Papanicolaou (1943)- normal
images
images
Class I. Normal cells of squamous
Class I. Normal cells of squamous
epithelium. Clean background of
epithelium. Clean background of
specimen. Leukocytes can occur.
specimen. Leukocytes can occur.
Class II. Normal cells from each line of
Class II. Normal cells from each line of
squamous epithelium. Inflammatory and
squamous epithelium. Inflammatory and
metaplastic cells, cervical cells of
metaplastic cells, cervical cells of
columnar epithelium, endometrial cells,
columnar epithelium, endometrial cells,
leukocytes, bacteria, Trichomonas
leukocytes, bacteria, Trichomonas
vaginalis, mucous.
vaginalis, mucous.
Anatomy and diagnosis
Pap smear classification
Pap smear classification
Papanicolaou (1943)- abnormal
Papanicolaou (1943)- abnormal
images
images
Class III. Normal and inflammatory cells
Class III. Normal and inflammatory cells
from each line of squamous and glandular
from each line of squamous and glandular
epithelium and dysplastic cells.
epithelium and dysplastic cells.
Class
Class
IV.
IV.
Like
Like
III
III
class and sparse
class and sparse
neoplastic cells
neoplastic cells
.
.
Erythrocytes can occur.
Erythrocytes can occur.
Grupa V.
Grupa V.
Large number of neoplastic cells
Large number of neoplastic cells
.
.
Large number of erythrocytes in
Large number of erythrocytes in
background of specimen.
background of specimen.
Anatomy and diagnosis
THE BETHESDA SYSTEM
1988
1991
2001
Anatomy and diagnosis
BETHESDA SYSTEM 2001
SPECIMEN TYPE: Indicate conventional smear (Pap smear) vs. liquid-based vs. other
SPECIMEN ADEQUACY
- Satisfactory for evaluation (describe presence or absence of endocervical/transformation
zone
component and any other quality indicators, e.g., partially obscuring blood,
inflammation, etc)
- Unsatisfactory for evaluation ... (specify reason)
- Specimen rejected/not processed (specify reason)
- Specimen processed and examined, but unsatisfactory for evaluation of epithelial
abnormality
because of (specify reason)
GENERAL CATEGORIZATION (optional)
- Negative for Intraepithelial Lesion or Malignancy
- Epithelial Cell Abnormality: See Interpretation/Result (specify ‘squamous’ or ‘glandular’
as
appropriate)
- Other: See Interpretation/Result (e.g. endometrial cells in a woman > 40 years of age)
AUTOMATED REVIEW
If case examined by automated device, specify device and result.
ANCILLARY TESTING
Provide a brief description of the test methods and report the result so that it is easily
understood by the
clinician.
Anatomy and diagnosis
BETHESDA SYSTEM 2001
INTERPRETATION/RESULT
NEGATIVE FOR INTRAEPITHELIAL LESION OR MALIGNANCY (state
whether or not there are organisms or other non-neoplastic findings)
ORGANISMS:
- Trichomonas vaginalis
- Fungal organisms morphologically consistent with Candida spp
- Shift in flora suggestive of bacterial vaginosis
- Bacteria morphologically consistent with Actinomyces spp.
- Cellular changes consistent with Herpes simplex virus
OTHER NON-NEOPLASTIC FINDINGS (Optional to report; list not inclusive):
- Reactive cellular changes associated with
inflammation (includes typical repair)
radiation
intrauterine contraceptive device (IUD)
- Glandular cells status post hysterectomy
- Atrophy
OTHER
- Endometrial cells (in a woman > 40 years of age)
(Specify if ‘negative for squamous intraepithelial lesion’)
Anatomy and diagnosis
BETHESDA SYSTEM 2001
INTERPRETATION/RESULT
EPITHELIAL CELL ABNORMALITIES
SQUAMOUS CELL
- Atypical squamous cells: - of undetermined significance (ASC-US)
- cannot exclude HSIL (ASC-H)
- Low grade squamous intraepithelial lesion (LSIL)
encompassing: HPV/mild dysplasia/CIN 1
- High grade squamous intraepithelial lesion (HSIL)
encompassing: moderate and severe dysplasia, CIS/CIN 2 and CIN
3
with features suspicious for invasion (if invasion is suspected)
- Squamous cell carcinoma
GLANDULAR CELL
- Atypical: - endocervical cells/ endometrial cells/ glandular cells (NOS or specify in
comments)
- Atypical: - endocervical/ glandular cells, favor neoplastic
- Endocervical adenocarcinoma in situ
- Adenocarcinoma: - endocervical
- endometrial
- extrauterine
- not otherwise specified (NOS)
OTHER MALIGNANT NEOPLASMS: (specify)
Anatomy and diagnosis
Papanicolau and Bethesda
SQUAMOUS CELLS ABNORMALITIES
formerly CIN I, CIN II, CIN III
currently
currently
LSIL
LSIL
or LGSIL ( low grade sqamosus interaepithelial
or LGSIL ( low grade sqamosus interaepithelial
lesion)
lesion)
-
encompassing: HPV/mild dysplasia/CIN 1
HSIL or HGSIL (high grade squamosus
interaepithelial lesion)
-
encompassing: moderate and severe dysplasia,
CIS/CIN 2 and CIN 3
and
HSIL
with features suspicious for invasion
Anatomy and diagnosis
COLPOSCOPY IN DIRECT
DIAGNOSIS OF
PATHOLOGICAL CHANGES
OF UTERINE CERVIX
Anatomy and diagnosis
CERVICAL EROSIONS
Simple cervical erosion
Papillariy cervical erosion
Follicular cervical erosion
Sanguinans cervical erosion
Anatomy and diagnosis
MAKROSCOPIC IMAGE OF CERVICAL
EROSION by Matthews and Hymms
Erosion I
º
-
2% of
carcinomas
Erosion II º-
27% of
carcinomas
Erosion III º-
54% of
carcinomas
Erosion IV º-
17% of
carcinomas
Anatomy and diagnosis
Hinselmann 1924
COLPOSCOPY 4 – 50 x
magnification
......
WIDEN COLPOSCOPIC
EXAMINATION
Anatomy and diagnosis
WIDEN COLPOSCOPIC
EXAMINATION
3% acetic acid- Hinselmann test
Lugol solution- Lahme-Schiller test
3-10% silver nitrate
hematoxylin- Antoine test
toluidine blue- Richart test
noradrenaline, vasopressin test
Filters
Anatomy and diagnosis
Anatomy and diagnosis
Anatomy and diagnosis
Anatomy and diagnosis
Anatomy and diagnosis
Anatomy and diagnosis
Anatomy and diagnosis
Anatomy and diagnosis
SUSPICIOUS COLPOSCOPIC
IMAGES
1.
Leukoplakia
2.
Punctate lesions
3.
Papillary basis
4.
Erosion
5.
Abnormal vascular pattern
6.
Jodide negative areas of
paraepidermoidal epithelium
Anatomy and diagnosis
Anatomy and diagnosis
Anatomy and diagnosis
Anatomy and diagnosis
Anatomy and diagnosis
Anatomy and diagnosis
Anatomy and diagnosis
VAGINITIS:
Trichomonas vaginalis
Candida albicans
Bacterial Vaginosis
Allergy and atrophy
Anatomy and diagnosis
Vaginal pH in diagnostic the
vaginal infections
Physiologic
BV
vaginal pH
4.5
Candidiasis
Trichomoniasis
Anatomy and diagnosis
Bacterial Vaginosis
Clinical syndrome recognized as a
polymicrobial superficial vaginal
infection involving a loss of the
normal lactobacilli and an
overgrowth of anaerobes.
It may be the cause of up to one half
of cases of vaginitis in all women
and the cause of from 10 to 30
percent of cases in pregnant women
Anatomy and diagnosis
Diagnostic Criteria for
Bacterial Vaginosis
Homogeneous vaginal discharge (color and
amount may vary)
Presence of clue cells (greater than 20%)
Clue cells -epithelial cells with clumps of bacteria
on their surface
Amine (fishy) odor when potassium
hydroxide solution is added to vaginal
secretions (commonly called the "whiff test")
Vaginal pH greater than 4.5
Absence of the normal vaginal lactobacilli
NOTE: At least three of these criteria must be present for diagnosis.
Anatomy and diagnosis
Morbidity Associated with
Bacterial Vaginosis
Post induced-abortion pelvic inflammatory
disease
Post-hysterectomy vaginal cuff cellulitis
Plasma cell endometritis
In pregnant women:
Amniotic fluid infection
Clinical chorioamnionitis
Postpartum endometritis
Premature rupture of the membranes
Preterm delivery
Low birth weight
Anatomy and diagnosis
Treatment Regimens for
Bacterial Vaginosis
Oral treatment
Metronidazole
Clindamycin
Topical treatment
Clindamycin 2%
vaginal cream
Metronidazole vaginal
gel
500 mg twice daily for
seven days
or
2 g in a single dose
300 mg twice daily for
seven days
5 g at bedtime for
seven days
5 g twice daily or at
bedtime for five days
Anatomy and diagnosis
INFERTILITY
DIAGNOSIS
Anatomy and diagnosis
Hysterosalpingography
(HSG)
Hysterosalpingogram- x-ray imaging
of the uterus and fallopian tubes
after instillation of a contrast liquid
Routine infertility evaluation (basic
test)
Assess morphology of endocervical
canal, uterine cavity, tubes.
Rule out tubal occlusion, synechiae,
uterine anomalies.
Anatomy and diagnosis
Contraindications to HSG:
1.
active PID with abdominal
tenderness or palpable mass
2.
recent uterine/tubal surgery
3.
active uterine bleeding
4.
pregnancy (schedule exam before
ovulation to avoid early
pregnancy)
Anatomy and diagnosis
Normal hysterosalpingogram.
A smooth triangular uterine cavity and spill
from the ends of both tubes.
Anatomy and diagnosis
HSG showing a normal uterus and blocked
tubes
No "spill" of dye is seen at the ends of the
tubes
Anatomy and diagnosis
Hysterosalpingogram showing a uterus with
a myoma that is pushing in to the cavity.
Anatomy and diagnosis
Tubal Recannulization and
Selective Salpingography
Anatomy and diagnosis
Selective hysterosapingography, or proximal
tubal cannulization may open the tubes
avoiding surgery.
Anatomy and diagnosis
LAPAROSCOPY
Anatomy and diagnosis
The camera and instruments are inserted into the
abdomen or chest through small skin cuts allowing
the surgeon to explore the whole cavity without the
need of making large standard openings dividing
skin and muscle.
Anatomy and diagnosis
After the cut is made in the umbilical area a special
( Veress) needle is inserted to start insufflation. A
pressure regulator CO2 insufflator is connected to
the needle. The pressure obtained should not be
beyond 15 mmHg.
Anatomy and diagnosis
After satisfactory insuflation the needle is
removed and a 10 mm trocar is inserted through
the previous umbilical wound.
Anatomy and diagnosis
Pelvic laparoscopy is used both for
diagnosis and for treatment. It may
be recommended for:
pelvic pain due to
uterine tissue found outside the uterus in the abdomen
(endometriosis)
infections (pelvic inflammatory disease) not responsive to drug
therapy
suspected twisting (torsion) of an ovary
ovarian cyst
scar tissue (adhesions) in pelvis
puncture through the uterus (uterine perforation) following D & C or
by an IUD
evaluation of infertility
sterilization (tubal ligation)
evaluation and removal of an abnormal pelvic mass (such as in a
fallopian tube or ovary) that was confirmed previously by abdominal
ultrasound
removal of uterine fibroids (myomectomy)
removal of uterus (hysterectomy)
surgical treatment of tubal pregnancy in a hemodynamically stable
patient
evaluation of a woman who may have appendicitis or salpingitis
Anatomy and diagnosis
Laparoscopic view of a normal pelvis.
Uterus in midline. Tubes and ovaries (white
structures) also visible.
Anatomy and diagnosis
Photo shows blood-stained ascites fluid with
an adhesion of small bowel to the
abdominal wall.
Anatomy and diagnosis
The omentum with white deposits which
represent metastatic tumor.
Anatomy and diagnosis
A biopsy is taken of one of the tumor
deposits on the abdominal wall.
Anatomy and diagnosis
The ectopic pregnacy is visualized in the
ampullary region of the left fallopian tube.
Anatomy and diagnosis
Contraindications to
laparoscopy:
Circulatory and respiratory
insufficiency
Hypovolemic shock
Ileus
Peritonitis
Abdominal or diaphragmic hernia
Tumors in abdominal cavity
Anatomy and diagnosis
Pelvic laparoscopy is also not
recommended for patients
with:
severe obesity
existing severe pelvic adhesions
from previous surgeries
Anatomy and diagnosis
Pelvic Laparoscopy: Risks
Risks for any anesthesia are:
•
reactions to medications
•
problems breathing
Risks for any surgery are:
•
bleeding
•
infection
•
damage to adjacent organs
Anatomy and diagnosis
HYSTEROSCOPY
Assess the endocervical canal,
uterine cavity and uterine
openings of the oviducts.
Enables to make the intrauterine
operations.
Anatomy and diagnosis
Hysteroscopic view of a uterine septum.
A septum can cause recurrent miscarriage.
Anatomy and diagnosis
A large polyp at the top of the uterine cavity
Anatomy and diagnosis
The loop of the resectoscope can be seen in the
foreground at the internal os of the cervix and the
myoma in the background. The endometrium
appears atrophic because the patient was treated
preoperatively with a GnRH agonist to diminish the
size of the myoma
Anatomy and diagnosis
The myoma is released by progressive shaving of the
stalk. The loop of the resectoscope is placed at the
most distant portion, and current is applied as the
resectoscope is drawn toward the surgeon.
Anatomy and diagnosis
Contraindications to
hysteroscopy:
Infections of reproductive organs
Massive bleeding from uterus
Pregnacy
Cervical cancer
Anatomy and diagnosis
Hysteroscopy.
Risks.
Uterine perforation
Bleeding
Infection
Pulmonary embolism (rare)
Anatomy and diagnosis
Tumor markers.
Useful in the follow-up
More useful markers:
β-HCG- in gestational trophoblastic neoplasia
CA 125- in ovary cancer, but also
endometrial, cervical and breast cancer
genetic markers : BRCA1 and BRCA2
mutations
CA 19-9- in ovary cancer
